Transoral ultrasound for bedside diagnosis of vertebral artery dissection in ICU patients with limited cervical access: a case report.

Abstract

Introduction: Vertebral artery dissection (VAD) is a serious complication of cervical trauma. Standard imaging such as computed tomography angiography (CTA), magnetic resonance angiography (MRA), and duplex ultrasonography (DUS) may be limited in critically ill patients. This case report aims to describe the innovative application of transoral ultrasound (TOUS) for bedside diagnosis of VAD in an intubated intensive care unit (ICU) patient.

Case presentation: A 75-year-old woman with C2 fractures and compromised cervical access was admitted after a motor vehicle accident. Standard cervical vascular ultrasound was technically limited due to the presence of an endotracheal tube and cervical immobilization. Bedside TOUS was performed by an intensivist with over 15 years of ultrasonography experience using a microconvex endocavitary probe (4-9 MHz, footprint 10 mm) with color and power Doppler, PRF range of 1-3 kHz, wall filter 50 Hz, and optimized gain settings. The patient was sedated and mechanically ventilated, allowing optimal tolerance. The left vertebral artery V2 segment demonstrated a high-resistance waveform proximally and a filiform Doppler signal distally, suggesting dissection. CTA performed subsequently confirmed VAD at C1-C2.

Conclusion: Our case demonstrates that TOUS enables bedside detection of vertebral artery dissection via direct insonation of the distal vertebral artery. This approach is particularly feasible in intubated ICU patients and allows access to segments not visible with standard cervical windows. Limitations include the need for operator expertise and reduced tolerability in non-intubated patients. Overall, TOUS represents a practical and innovative tool for diagnosing VAD in critically ill trauma patients when conventional imaging is limited.